HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 PADDOCK LANE 5/21/2024 Commonwealth of Massachusetts ���Iac�h pndrjveC
= City/Town of 10'r<
System Pumping Record 202�
Form 4 MAC 2
�M J'
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. ----
HOUSE: front back side rear left Ight
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System ocation'.
on the computer,
use only the tab
key to move your Address
cursor-do not MA ��C5 e��
use the return key. City/Town State Zip Code
2. S%Ir�
m Owner: ..
n,e
Name
ieitm
Address(if different from location)
MA
Clty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date L 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) (�] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): r
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condign of component pumped:
0 CAA,
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD3
Name Vehicle License Num r
Bateson Enterprises, Inc.
Company
T oca n where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1